Seung Ik Ahn

Surgery Versus Transarterial Chemoembolization for Solitary Large Hepatocellular Carcinoma of BCLC Stage A

Background/AimsThe aim of this study was to compare the outcomes of surgery and transarterial chemoembolization (TACE) for a solitary huge hepatocellular carcinoma (HCC) of Barcelona Clinic Liver Cancer (BCLC) stage A.MethodsOne hundred twenty-three consecutive patients with a solitary large (>5xa0cm) HCC classified at the BCLC stage A were analyzed. The posttreatment survival outcomes of patients that underwent surgery or TACE were compared.ResultsThe median age was 58xa0years (range, 29–90xa0years). The most common cause of HCC is hepatitis B virus infection (61.8xa0%). Median tumor size was 8.0xa0cm (range, 5.1–25xa0cm), and 97 patients (78.9xa0%) were of Child–Turcotte–Pugh class A. Median posttreatment follow-up duration was 18xa0months (range, 0.1–136xa0months). Of the 123 patients, 62 (50.4xa0%) underwent surgery and 61 (49.6xa0%) underwent TACE. Cumulative overall survival rates in the surgical group at 1, 3, and 5xa0years were significantly higher than those in the TACE group (83.2, 75.7, and 65.0xa0% vs 68.5, 45.0, and 17.5xa0%, respectively, Pu2009<u20090.01). In subgroup analysis, the cumulative overall survival in both surgical groups was significantly greater than in corresponding TACE subgroups (Pu2009=u20090.04 for ≥8-cm subgroup and Pu2009<u20090.01 for 5- to 8-cm-sized subgroups). Multivariate analysis showed that a larger tumor size (≥8xa0cm) (hazard ratio [HR] 2.14, Pu2009=u20090.02) was significantly associated with posttreatment mortality, whereas surgery (HR 0.37, Pu2009<u20090.01) compared with TACE was inversely associated with posttreatment mortality.ConclusionsSurgery may be the more effective treatment modality than TACE for a solitary large HCC of the BCLC stage A, regardless of tumor size.

Extrapulmonary Small Cell Carcinoma of the Liver: Clinicopathological and Immunohistochemical Findings

Patients with primary small cell carcinoma of the liver have rarely been described in medical literature. Knowledge of clinical, pathological and immunohistochemical properties remains limited. We described an 82-year-old female patient with primary small cell carcinoma of the liver. Histologically, the tumor showed typical morphology of a pulmonary small cell carcinoma. Immunohistochemically, the tumor revealed neuroendocrine differentiation; positive reaction for chromogranin, synaptophysin, CD56, and neuron specific enolase. The tumor was also positive for TTF-1 and c-kit but completely negative for hepatocyte, carcinoembryonic antigen, cytokeratin 7; 19; and 20. Herein, we discussed the clinical, pathological and immunohistochemical findings of extrapulmonary small cell carcinoma of the liver and reviewed the relevant literature.

Preliminary results of binding pancreaticojejunostomy

Backgrounds/Aims The post-operative complications and clinical course of pancreaticoduodenectomy (PD) largely depend on the pancreaticojejunostomy (PJ). Several methods of PJ are in clinical use. We analyzed the early results of binding pancreaticojejunostomy (BPJ), a technique reported by SY Peng. Methods We retrospectively reviewed the clinical results of patients who received BPJ in Inha University Hospital from 2006 to 2011. 21 BPJs were performed with Pengs method. The definition of postoperative pancreatic fistula (PF) was a high amylase content (>3 times the upper normal serum value) of the drain fluid (of any measurable volume), at any time on or after the 3rd post-operative day. The pancreatic fistula was graded according to the International Study Group for Pancreatic Fistula (ISGPF) guidelines. Results Of the 21 patients who received BPJ, 11 were male. The median age was 61.2 years. PD surgery included 4 cases of Whipples procedures and 17 cases of pylorus-preserving PD. According to the post-operative course, 16 patients recovered well with no evidence of PF. A total of 5 patients (23.8%), including 3 grade A PFs and 2 grade C PFs, suffered from a pancreatic fistula. 3 patients with grade A PF recovered with conservative management. Conclusions The BPJ appears to be a relatively safe procedure based on this preliminary study, but further study is needed to validate its safety.

Risk factors of postoperative ascites on hepatic resection for hepatocellular carcinoma

Backgrounds/Aims The aim of this study was to identify the risk factors of the development of large amounts of ascites (LA) after hepatic resection for hepatocellular carcinoma (HCC). Methods The medical records of 137 consecutive patients who underwent hepatic resection for HCC from January 2010 to December 2014 were retrospectively reviewed. Patients were divided into two groups: LA group, with ascites drainage >500 cc per day over 3 days (n=37) and control group (n=100). Preoperative and intraoperative clinical variables were compared between the two groups. Results Thirty-seven (27.0%) patients developed LA. Platelet counts of <100,000/mm3, ICG-R15 >10%, CTP scores of 6 or 7 points, major resection, the presence of cirrhosis, preoperative ascites, and portal hypertension were significantly more frequent in LA group. Multivariate analysis revealed that a higher CTP score (HR=4.1), the presence of portal hypertension (HR=26.7), and major resection (HR=18.5) were independent and significant risk factors of postoperative ascites development. Persistent refractory ascites developed in 6 (16.2%) patients who succumbed to hepatic failure during follow-up. Conclusions Patients with a 6 or 7 point CTP score, major hepatic resection and/or portal hypertension were more likely to develop LA and experience deterioration of liver function after surgery. The selection of patients for hepatic resection should be based on a balanced assessment of the benefits of HCC treatment and risk of postoperative liver failure.

Efficacy and feasibility of laparoscopic subtotal cholecystectomy for acute cholecystitis

Backgrounds/Aims For patients with acute cholecystitis, conversion from laparoscopic cholecystectomy to open surgery is not uncommon due to possibilities of serious hemorrhage at the liver bed and bile duct injury. Recent studies reported successful laparoscopic subtotal cholecystectomy for acute cholecystitis. The purpose of this study was to determine the efficacy and feasibility of such an operation based on the experience of surgeons at our facility. Methods In this study, we enrolled 144 patients who had received either laparoscopic subtotal cholecystectomy (LSC), laparoscopic cholecystectomy (LC), or open cholecystectomy (OC) for acute cholecystitis from January 2004 to December 2009 at the Department of Surgery of our hospital. Their symptoms, signs, operative findings, pathologic results and postoperative results were compared and analyzed. Results There were 26 patients in the LSC group 80 in the LC group and 38 in the OC group. There were no differences in mean age, sex, and symptoms of acute cholecystitis. The LSC group showed higher CRP levels (p<0.001) and a higher grade according to the Tokyo criteria (p=0.001). The mean operative time was 115.6 minutes and mean blood loss was 158.9 ml without intra-operative or postoperative transfusion. There werent any bile duct injuries during the operation. No group suffered bile leakage. Drains were removed 3.3 days after the operation in the LC group, the shortest time compared to the other groups (p<0.001). LC and LSC groups demonstrated shorter postoperative hospital days and time to diet resumption than the OC group (p<0.001). Conclusions LSC appears to be a safe and effective treatment in cases of severe acute cholecystitis that require consideration of conversion to open surgery.

Cutaneous metastasis as an initial presentation of a non-functioning pancreatic neuroendocrine tumor

Non-functioning pancreatic neuroendocrine tumors (NF-PNETs) are rare tumors that account for 2% of all pancreatic malignancy. About 60% of NF-PNETs present distant metastases and usually hepatic metastases. However, cutaneous metastases are very rare. Herein, we report our experience with a 60-year-old male who visited our outpatient clinic with a mass on his left hip. An abdominal computerized tomography scan demonstrated not only a left hip mass and an enlarged left inguinal lymph node, but also a huge heterogeneous enhancing mass on the pancreas. Initially, we removed the metastatic lesions, which was a small cell neuroendocrine carcinoma with 50% of the Ki-67 index in the histopathological report. After 3 wk, we performed a total pancreatectomy and a total gastrectomy. Four weeks after the 1(st) operation, we detected a recurrence at the operative bed on his left hip, and subsequently removed the recurring mass. The patient was receiving chemotherapy based on etoposide and cisplatin treatment.